Citation Nr: 21023942 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 18-15 582 DATE: April 21, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2007 to April 2008, February 2010 to April 2011, and May 2011 to May 2012. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from 2015 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2019 and April 2020, the Board remanded this appeal for further evidentiary development. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). Service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety This matter was most recently before the Board in April 2020. At that time, the Board found that a remand was necessary to obtain an adequate VA medical opinion, as the prior examinations and opinions of record were inadequate and there had not been substantial compliance with the prior Board remand. Specifically, the Board noted that, despite the Veteran’s treatment records containing a diagnosis of depression and additional symptoms of a psychiatric condition recorded that included sleep disturbances, nightmares, periods of substance abuse and homelessness, and some suicidal ideation, the VA examinations did not indicate a diagnosis of PTSD or any other psychiatric condition. In particular, the Board noted that the most recent examination of February 2020 did not include any rationale for the conclusion that the Veteran did not have any symptoms meeting the diagnostic criteria for any mental disorder and did not explain how that opinion was consistent with the other evidence of record, given the Veteran’s diagnosis of depression in his VA treatment records. As such, the Board directed the RO to obtain an adequate medical opinion addressing whether the Veteran has a psychiatric condition and whether such is due to or aggravated by his active duty service. The Board additionally requested, if the examiner were to find that the Veteran did not have a diagnosis of a psychiatric condition, that an explanation be provided for that conclusion with a basis for the opinion and requested that the examiner address the Veteran’s VA treatment records and explain why the examiner had reached a different conclusion. An addendum opinion was obtained in May 2020, and, unfortunately, the Board finds that this opinion is wholly inadequate. The two-sentence opinion provided by the examiner only stated that the Veteran’s symptoms of record did not meet the diagnostic criteria for any mental disorder and that aggravation was not possible without a diagnosis. Despite the clear request from the Board, the examiner provided no rationale for the opinion and failed to address the diagnosis of depression provided in the Veteran’s VA treatment records—or explain how or why the examiner reached a conclusion that the Veteran has no diagnosis despite the evidence to the contrary. A remand by the Board confers on the claimant a legal right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessities remand for corrective action. Id. Substantial compliance with the remand order, not strict compliance, is required. Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010); Dyment v. West, 13 Vet. App. 141, 147 (1990). Failure of the Board to ensure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. Stegall, 11 Vet. App. at 271. The development conducted following the April 2020 Board remand is wholly inadequate, and, in this regard, there has not been substantial compliance with the April 2020 remand directive. Stegall, 11 Vet. App. at 271. An additional remand is, thus, necessary for corrective action, to include obtaining an adequate VA opinion that addresses the nature and etiology of the Veteran’s psychiatric condition and that provides adequate rationale for any provided opinion. Accordingly, this matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate VA examiner to determine the current nature and etiology of the Veteran’s acquired psychiatric disorder, to include PTSD, depression, and anxiety. A new VA examination may be conducted if deemed necessary. The claims file, to include a copy of this remand, must be made available to and be reviewed by the examiner. The examiner is asked to: a. Identify/diagnose any acquired psychiatric disability that presently exists or that has existed during the appeal period. In doing so, the examiner is specifically directed to the Veteran’s VA treatment records which include a diagnosis of depression as well as reports of additional psychiatric symptoms. If the examiner finds that the Veteran does not have a diagnosis of a psychiatric disorder, the examiner should clearly explain the basis for that opinion, to include explaining why the examiner has reached this contradictory conclusion despite the diagnosis of depression in the Veteran’s VA treatment records. b. Opine whether it is at least as likely as not (i.e., at least a 50 percent probability or greater) that the Veteran’s diagnosed acquired psychiatric disorder onset in, or is otherwise related to, his service or any incident therein. The examiner is advised that the Veteran is competent to report his symptoms and history and that such reports must be acknowledged and considered in formulating the opinion requested herein. A clear explanation for all opinions would be helpful, as well as a rationale for the opinions rendered, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is unable to provide an opinion, he or she should explain why. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Goreham The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.